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Practical challenges in
Nutritional Support of
Pre & Post Liver Transplant
Daphnee.D.K
Head – Department of Dietetics
Apollo Hospitals, Chennai
Prevalence of Malnutrition
• 20% - Compensated liver disease
• >80% - Decompensated liver disease
• 100% - Await Liver Transplant
Antonio J. Sanchez; Mayo Clinic Foundation, 2006
Malnutrition in CLD - Cause
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated by
Jeanette M. Hasse and Laura E. Matarese, 2002.
Abnormalities of Poor nutrient
metabolism intake
MALNUTRITION
Morbidity
Mortality
Malnutrition in CLD - Cause, Etiology
Causes Etiology
Reduced nutrient
intake
Decreased Intake
and anorexia
• Unpalatable Diets
( Na & H2O restriction )
•Disgeusia due to
micronutrient deficiencies
(Zn or Mg)
•Anorexia effect caused
by increased levels of
proinflammatory
cytokines and leptin
Malnutrition in CLD – Cause,Etiology Causes Etiology
Reduced nutrient intake
•Nausea & early satiety •Tense Ascites
•Gastroparesis
•Small bowel dismotility
•Bacterial over growth
•Starvation •Hospitalization
•Invasive diagnostic
procedure requiring fasting
•Gastrointestinal bleeding
and endoscopic therapies
Reduced Intestinal
absorption
•Maldigestion
•Bacterial over growth
•Diarrhea
•Pancreatic insufficiency in
Alcohol abuse and /or
Cholestasis)
•Drugs (i.e.,
nonabsorbable
disaccharides, antibiotics
and cholestyramine)
Causes Etiology
Altered Metabolism/
Expenditure
•Protein Catabolism
•Increased energy
expenditure
•Insulin resistance
•Increase fat turnover
• Reduced hepatic
protein synthesis and
increased protein
breakdown
•During ascites and
bacterial infections
•Hepatocellular
carcinoma
•Hyperinsulinemia and
reduced nonoxidative
glucose metabolism
•Increased lipolysis due
to more rapid transition
to starvation
•Fats are utilized as
alternative energy
source
Malnutrition in CLD – Cause, Etiology
Altered metabolism CHO
• Increased
Catabolic hormones (as not degraded by liver)
Gluconeogenesis
• Decreased
Post prandial glucose storage
Glycogen stores (accelerated starvation)
Accelerated Starvation Fat – major substrate for energy
72hrs of Starvation Vs Overnight fast
(Normal adult) (Cirrhotic pt)
Fat & Muscle
Breakdown
Increases Gluconeogenesis Muscle Wasting
Altered metabolism
Protein
• Imbalance in BCAA and aromatic amino acids Expected Ratio – 3.5:1 Decreased to 1:1 - increased cerebral uptake of aromatic amino acids - promoting the synthesis of false neurotransmitters •Muscle wasting
Fat
(preferred
fuel)
• Nocturnal fat metabolism - impaired synthesis
PUFA from EFA
• Decreased PUFA associated with severity of
malnutrition
Malnutrition in CLD - Pathophysiology
Algorithm content developed by John Anderson, PhD, and Sanford C. Garner, PhD, 2000. Updated
by Jeanette M. Hasse and Laura E. Matarese, 2002.
Nutrition Assessment
Subjective Global Assessment (SGA)
HISTORY
Weight change GI symptoms
(nausea,
vomiting,
diarrhea,
constipation)
Co-
morbidities
cont…
Muscle Wasting
& Fat stores
Dietary Intake
Physical
Activities
Guidelines for estimating fluid
weight (kg)
Category Ascites Odema
Minimal 2.2 1.0
Moderate 6.0 5.0
Severe 14.0 10.0
• Grade 1 (mild). Ascites is only detectable by ultrasound examination.
• Grade 2 (moderate). Ascites causing moderate symmetrical distension
of the abdomen
• Grade 3 (large). Ascites causing marked abdominal distension.
Fluid retention in ESLD &
relevance to nutrition
• Impairs food intake
• Energy expenditure
increases
• Negative nitrogen balance
Factors influencing the accuracy of common
indices used for nutritional assessment Body weight •Water restriction and fluid
accumulation
•Changes in body composition
Visceral proteins •Decreased liver synthesis
•Increased volume of distribution
Anthropometry •Fluid retention
Immunological status •Hypersplenism
•Abnormal immunological reactivity
Creatinine excretion
•Renal insufficiency
Bioelectrical impedance analysis
•Presence of ascites
Nutritional Goals
• Correct malnutrition
• Prevent metabolic complications
• Improve quality of life
• Reduce Perioperative complications
• Nutrition education – Individual care
plan
Nutritional Management - CLD
• Energy: 35 to 40 kcal/kg dry weight
BEE x 1.2 to 1.3, depending on degree of
malnutrition
CHO: 60 – 70 % of cals as complex & simple CHO
• Protein: 1.2 to 1.5 g/kg dry wt depending on degree
of malnutrition, malabsorption, metabolic stress
– To maintain
- Muscle mass
- Protein levels in the blood
ESPEN Guidelines on Enteral Nutrition: Liver disease 2006
• Hepatic Encephalopathy
- BCAA formula
• Fat: 25% to 40% of kcal
• Electrolytes: restrict sodium with edema or ascites
(2 - 4 g/day)
• Fluid: restrict fluid if hyponatremia is present
• Individualized
Nutritional Management - CLD
Practical Difficulties in meeting
Nutrition Prescription Study Design : Single Center,
Prospective study
Study Duration : May to August 2013
Setting : Liver ICU, Tertiary care
hospital, Chennai
Study Population : ESLD
Data Collected : Baseline demographics
Nutritional status
- Subjective Global Assessment (SGA)
- Nutrition Data
Baseline Demographics
Mean ± Std Range
Age (yrs) 45.4±9.32 30 - 58
Height (cms) 168.5±10.6 157 - 180
Weight (kg) 75.3±17.01 36 - 94
BMI (kg/m2) 26.45±5.08 14.61 - 32.86
MAC (cms) 26.08±4.25 18 - 32
MELD 19.6±4.46 11 - 23
Well Nourished 7%
Moderately Malnourished
93%
Baseline Nutritional Status
Child B 13%
Child C 87%
Classification - Child Pugh Score
0
10
20
30
40
50
60
70
80
90
100
Calorie Protein
69
49
% Nutritional Target Achieved
Calorie Protein
How did we achieve
Nutrition Goals?
• Nutrition Monitoring
• Oral intake was monitored using a
food and fluid chart by the Nurses
• Calorie Count – done by the Dietitian
• Labs : Hb, Serum Albumin,
Lymphocytes, Na, K etc.,
Nutrition Monitoring – Oral diet
How did we achieve
Nutrition Goals?
• Nutrition Education
– Educated on the salt and fluid restrictions
– Emphasized on
• Increased caloric and protein intake
• Oral Nutrition Supplement (ONS)
• Nocturnal tube feed suggested if oral
intake is not adequate
Reasons for Deviation
• Salt & fluid restriction
• Fever, Infection & Abdominal Pain
• Hepatic encephalopathy
• Nausea
• Procedures
General recommendations
• Small frequent meals
• Monitor calorie count
• TPN - GI dysfunction is present
• Aggressive nutrition support
- Highly Individualized
- Minimize catabolism
- Slow the deterioration of
nutritional status
Post -operative state
Immediate Post - operative state
Nutrition Status is affected by
• Graft function
• Pre - existing malnutrition
• The stress response to surgery
• Catabolic effects of high dose steroids
Nutrition Care Plan
• Post OP Nutrient recommendations
Energy – 1.2 – 1.3 times BEE
• BEE using Harris Benedict equation
• AEE : 1.3×BEE
Protein - 1.3 – 2g / kg / day
• American Association for the Study of Liver Disease
Effect of Nutrition Support in the post
liver transplant Indian Adult Patients
Study design : Single centre, Prospective
Study period : Jan - Sep’13
Sampling technique: Random
Sample size : 27 subjects
Setting : Liver unit, Tertiary care hospital
Inclusion criteria : All Indian adults who underwent
transplant for the first time
Exclusion criteria : All paediatric and international pts
On admission, the demographic, biochemical, nutritional,
and anthropometric details were noted
Baseline Characteristics
Characteristics of Patients
Mean±Std Range
Age(yrs) 47.5±9.59 25-60
Height(cms) 163.6±10.05 143-182
Weight(Kg) 69.5±13.56 36-95.5
BMI(Kg/m2) 26.01±5.14 14.79-38.94
MAC(cms) 25.8±4.13 18-35
MELD 18.1±3.78 11 - 23
A/G Ratio 0.9±0.36 0.3 - 1.8
Objectives
• To study the effect of
– disease severity on nutritional status and
outcomes
– nutritional intervention in A/G ratio, LOS in
ICU and hospital and nutritional status of the
patients
– ethanol and non-ethanol related ESLD and
type of transplant (DDLT and LDLT) in
nutritional status and outcome
DDLT 70%
LDLT 30%
Type of Liver Transplant
Ethanol 50%
Cryptogenic 25%
HBV 4%
HCC 4%
HCV 17%
Type of Diagnosis
Well Nourished 4%
Moderately Malnourished
96%
Baseline Nutritional Status
Child B 33%
Child C 67%
Classification - Child Pugh Score
0
10
20
30
40
50
60
70
80
90
100
Day-1 Day-3 Day-5 Day-7 Day of Discharge
37.78
68.93
82.4 89.78
94.9
% C
alo
rie A
ch
ieved
Days
% Calorie Achieved
Day-1 Day-3 Day-5 Day-7 Day of Discharge
0
10
20
30
40
50
60
70
80
90
Day-1 Day-3 Day-5 Day-7 Day of Discharge
20.69
51.25
64.4
72.5 80.32
% P
rote
in A
ch
ieved
Days
% Protein Achieved
Day-1 Day-3 Day-5 Day-7 Day of Discharge
0
10
20
30
40
50
60
70
80
90
100
Calorie Protein
74.3%
60.3%
Target Vs Achieved Calorie Protein
Results • Strong correlation between the disease severity score
(child) and the nutritional status (SGA) of the patients
• There was an improvement in weight and A/G ratio of
the patients after nutritional intervention and was
significant (p<0.001)
• Length of stay in ICU and Hospital were 9.9+/6.9 and
16.07+/10.78 respectively
• LOS of child - C class in the hospital (17.5 days) was
comparatively higher than the child - B class (13.1
days)
• There is a strong correlation between the ethanol
intake and the nutritional status (SGA) of the patients
(p< 0.014)
Conclusion
• A protocolized nutritional support and
close monitoring reduced the risk of
adverse outcomes in our study population
How did we achieve
Nutrition Goals?
• Nutrition Monitoring
• Oral intake was monitored using a
food and fluid chart by the Nurses
• Calorie Count – done by the Dietitian
• Labs : Hb, Serum Albumin,
Lymphocytes, Na, K etc.,
• Protocolized treatment plan
How did we achieve
Nutrition Goals?
• Nutrition Education
– Post transplant diet education
– Emphasized on
• Increased caloric and protein intake
• Oral Nutrition Supplement (ONS)
• Food hygiene and safety
Reasons for Deviation
• Surgical stress
• Fever, Infection & Abdominal Pain
• Nausea & Vomiting
• Procedures
THANK YOU